Inguinal lymphadenitis



OVERVIEW

Definition.

Inguinal lymphadenitis, an inflammation of the lymph nodes in the inguinal region, can result from a variety of factors.

Usually, inguinal lymphadenitis is narrowly defined as acute nonspecific infectious lymphadenitis, most often caused by chronic injury and infection of the inguinal lymph node drainage areas such as the lower extremities and perineum.

Inguinal lymphadenitis manifests as enlarged lymph nodes in the groin, accompanied by fever, pain and tenderness. When the inflammation is severe, the enlarged lymph nodes may adhere to form a mass, and the skin on the surface may become red and warm, and the pain may worsen [1]. If the lymph node is suppurating, it can be touched with fluctuating sensation, and even with pus rupture.

Classification

According to the etiology, histopathologic changes and clinical manifestations, it can be divided into reactive lymphadenitis and specific lymphadenitis.

Reactive lymphadenitis

It is the most common benign lesion of lymph nodes with leukocytosis and lymph node enlargement caused by microbial infection or inflammatory stimuli. There are various causes of lymphadenitis, but the pathologic changes of reactive lymphadenitis are basically similar and lack specificity, so it is also called nonspecific lymphadenitis [2].

According to the time of onset of disease, it can be divided into acute and chronic nonspecific lymphadenitis.

Specific lymphadenitis

Some lymphadenitis caused by specific pathogenic microorganisms (e.g., fungi, rickettsiae, EBV, syphilis, Mycobacterium tuberculosis, etc.) have specific pathomorphologic changes. Associated pathogens may be found in diseased tissues, secretions, and body fluids, and specific drug therapy for the pathogens is required in clinical practice.

Lymphadenitis of unknown origin with specific clinical and pathologic features is also classified as specific lymphadenitis.

Causes

A variety of factors can lead to inguinal lymphadenitis. Injuries and infections of the lower extremities and perineum are the most common causes.

Pathogenesis

Acute nonspecific lymphadenitis

It is often due to inflammation of the inguinal lymph node drainage areas such as the lower limbs, lower abdomen, and vulva [3]. For example, cellulitis and onychomycosis of the lower extremities, infection and abscess after trauma to the lower extremities, orchitis and perianal abscess in the perineum.

Localized infections cause acute lymphadenitis in the inguinal region through lymphatic circulation routes. Common causative organisms include Staphylococcus aureus, Escherichia coli, and streptococcus. Localized redness, swelling, heat and pain, can be found in the enlarged lymph nodes and accompanied by tenderness, inflammation is very serious can be accompanied by fever, headache and other systemic symptoms. Most of them can be cured after anti-infection treatment.

Chronic non-specific lymphadenitis

Chronic non-specific infectious lymphadenitis can be transformed from acute lymphadenitis or caused by local chronic inflammation. There is often no obvious redness, swelling, heat and pain, most of the lymph nodes are mildly to moderately enlarged, and the enlarged lymph nodes may be adherent to each other, and there is no obvious tenderness.

Atopic lymphadenitis

Most of the inguinal lymphadenitis caused by atopic infections are caused by specific pathogens, such as tuberculosis, filariasis infection, syphilis, Haemophilus ducreyi, genital herpes, rickettsia, etc. [4].

Pathogenesis

Lymph nodes are important immune organs and defense barriers in the body and are divided into two major groups, superficial and deep. Inguinal lymph nodes generally refer to the superficial group of lymph nodes distributed in the inguinal region.

Various stimuli to which the organism is subjected, such as various types of pathogenic microbial infections, foreign poisons, foreign bodies, the organism’s own metabolic products, degenerated necrotic tissues, etc., can become antigens or sensitizers to stimulate the hyperplasia of lymphocytes, histiocytes, and dendritic cells in the lymph nodes, leading to the occurrence of lymph node enlargement and inflammatory reactions.

Symptoms

Inguinal lymphadenitis mainly manifests as localized redness, swelling and pain in the groin, and enlarged lymph nodes can be palpated, often with tenderness, which may be accompanied by systemic symptoms such as fever and headache.

Main symptoms

Acute non-specific lymphadenitis

Mostly caused by inflammation of the lower limbs, lower abdomen and genital organs.

In mild cases, lymph nodes are enlarged and painful, and enlarged and tender lymph nodes can be palpated.

When the inflammation worsens, the lymph nodes may adhere into a mass, and the skin on the surface becomes red and hot, and the pain worsens.

In severe cases, lymphadenitis may be fluctuating due to necrosis and formation of local abscess, or ulcerated and pus flow, and there are systemic inflammatory reactions such as fever and elevated white blood cells.

Chronic non-specific lymphadenitis

Chronic inflammatory reaction of the lymph nodes is usually not obvious to the patient, with nodules in the groin and occasional but mild pain.

Atopic lymphadenitis

Atopic lymphadenitis can be characterized by acute or chronic non-specific lymphadenitis depending on the urgency of the onset of the disease, including localized lymph node enlargement, pain, etc. It is often accompanied by other specific clinical manifestations depending on the specific pathogen of the infection.

The enlarged lymph nodes are of different sizes and of medium quality.

There may be low fever, night sweats, poor appetite, lethargy, fatigue and other symptoms of tuberculosis systemic toxicity, mostly seen in young adults.

Enlarged inguinal lymph nodes.

If complicated by obstruction of lymphatic reflux in the lower limbs, it may cause elephantiasis of the lower limbs.

History of being scratched or bitten by cats, dogs and other pets.

There may be herpes, pustules, scabs, or small ulcers on the skin at the site of cat scratches and bites, accompanied by mild fever.

There is unilateral localized lymph node enlargement.

There may be a history of impure sex.

There are multiple ulcers with pain on the perineum.

Inguinal lymph nodes are enlarged and tender and may form abscesses and ulcers, mostly unilateral.

Small painless papules or ulcers may appear on the external genitalia, anorectum, etc., which heal in a few days. Thereafter inguinal lymph nodes are enlarged, painful, and ulcerated, and multiple fistulas may develop.

Seek medical attention

If you notice swollen lymph nodes in the groin, you need to seek active medical attention. The doctor will ask about symptoms, medical history, previous tests and treatment.

Department of Medicine

General Surgery

When a nodule appears in the groin at the base of the thigh, you need to visit the general surgery department.

Infection, Dermatology and Venereology, Urology

After completing the initial tests, select the corresponding department for in-depth treatment based on the test results.

If the diagnosis is tuberculosis, the Department of Infectious Diseases should be consulted.

If the diagnosis is venereal disease, the Department of Dermatology and Venereology should be consulted.

If there are obvious symptoms such as urinary urgency, urinary pain and purulent discharge from the urethra, you should consult the Department of Urology.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of information, common questions

Tips for medical treatment

Choose the appropriate means of transportation to avoid prolonged walking and friction in the groin, which may aggravate the swelling and pain.

Do a good job of personal hygiene, clean your body and wear appropriate clothing to facilitate the doctor’s examination.

Preparation Checklist

Especially need to pay attention to the time of symptom onset, special performance, etc.

When did the lump appear in the groin area? Size? What is the nature of the lump?

Is it bilateral or unilateral?

Is there pain?

Is there any redness, swelling, or elevated skin temperature?

Is there any other discomfort in the affected lower limbs, lower abdomen, perineum, or other areas?

Is there any generalized discomfort such as fever, headache, or malaise?

Is there any history of traumatic infection of the lower limbs, lower abdomen, or perineum?

How is the recent sex life? Is there any history of unclean sex?

Any history of field activities?

Any mosquito bites?

Any history of scratching or clawing by dogs or cats?

Test results in the last six months, which can be brought to the doctor’s office.

Laboratory tests: blood routine, C-reactive protein, calcitoninogen, liver and kidney function, blood sedimentation, bacterial culture, blood culture, etc.

Imaging examination: ultrasonography of the urinary tract, ultrasonography of local soft tissues (inguinal area), CT of the abdomen, CT of the chest, etc.

Pathological examination: biopsy of lymph nodes in the inguinal area.

Medication use in the last 3 months, if there is a box or package of medication, carry it to the doctor

Anticonvulsant drugs: phenytoin sodium, carbamazepine, sodium valproate, etc [5-7].

Anti-infective drugs: amoxicillin, cephalosporin, etc.

Topical topical skin medications: beclomethasone, glycerite lotion, etc.

Anti-allergic drugs: loratadine.

Diagnosis

The diagnosis of inguinal lymphadenitis mainly relies on history, symptoms, laboratory tests, imaging tests, etc.

Diagnosis is based on

Medical history

History of trauma or infection to the lower extremities, lower abdomen, or external genitalia.

History of field activities.

History of impure sex.

History of phenytoin sodium use.

History of poisonous snake bite or mosquito bite.

History of cat and dog scratches.

Clinical manifestations

Generally there is obvious redness, swelling, heat and pain localized in the groin, often with limited lymph node enlargement accompanied by pain.

Site: generalized or localized lymph node enlargement.

Texture: Enlarged lymph nodes caused by infection are usually of medium texture.

Pressure: Pressure or spontaneous pain is usually inflammatory; severe swelling is common in noma infection with Haemophilus ducreyi. Enlarged lymph nodes due to cat scratch disease are confined and painful, and may become pus-filled, occasionally forming fistulas.

Fluctuating sensation and fistula: a fluctuating sensation suggests suppurative, necrotic softening of the lymph node. Tuberculous lymphadenitis, actinomycosis, or venereal inguinal lymphogranuloma may cause lymph nodes to break down and form fistulas.

Laboratory tests

The main purpose of laboratory tests is to identify the cause of the disease.

These two tests are often used to determine the presence and severity of infection.

Increased white blood cells and neutrophils suggest bacterial infection; increased lymphocytes suggest viral infection; elevated eosinophils suggest parasitic infection or allergic reaction.

Increased blood sedimentation suggests active tuberculosis, active rheumatic diseases, and so on.

This test is used to clarify the pathogen of infection. The main examination methods are blood culture, lymph node fistula secretion to find pathogens, sexually transmitted granuloma secretion chlamydia isolation and culture. Lymph node puncture material or drainage material smear for antacid bacilli or culture.

Exo-fibrio reaction is done in case of suspicion of scrub typhus (rickettsial infection).

Toxoplasma antibodies when toxoplasmosis is suspected.

PPD test is done in patients with history of tuberculosis exposure, low-grade fever, and suspicion of tuberculous lymphadenitis [8].

Imaging

Imaging examination can help doctors to clarify the specific situation of inguinal lymph nodes, observe their internal structure and generally determine the benign or malignant nature. Most patients only need to complete the ultrasound examination of the groin area and CT examination of the chest and abdomen.

Pathologic examination

Lymph node biopsy (excisional biopsy, puncture biopsy, etc.) may be performed to clarify the nature of inguinal lymphadenitis of unknown origin.

Differential diagnosis

Inguinal hernia/femoral hernia

Similarities: same inguinal mass.

Differences: Hernia presents as an intermittent, resettable or incarcerated inguinal mass that is large in size. There is no history of infection in the lower limbs or perineum, and there is usually no fever. If the incarcerated hernia causes abdominal infection, there may be fever, abdominal pain, and symptoms of intestinal obstruction. The diagnosis can be clarified by ultrasonography.

Amyand hernia appendicitis

Similarities: Amyand’s hernia occurs when the appendix is present in the hernia sac. When Amyand’s hernia is combined with appendicitis there is a painful lump in the groin area accompanied by fever.

Difference: when appendicitis is more inflamed and complicates perforation, a localized abscess with a painful mass in the groin may be present [9]. Abdominal ultrasound and CT can clarify the diagnosis.

Treatment

Aim of treatment: eradication, relief of symptoms, and control of disease progression.

Treatment principle: control inflammation, target the cause of the disease.

General treatment

If the symptoms of localized lymphadenitis are not serious, cold compresses and external anti-inflammatory and anti-swelling drugs can be applied.

Patients need to pay attention to rest, strengthen nutrition, and reduce physical exercise appropriately.

Medication

Antibacterial drugs

Sensitive antibiotics are often used, such as amoxicillin and cephalosporin.

Mainly for inguinal lymph node infection bacteria, nearby tissue and organ inflammation such as perianal infection.

Antifungal drugs can be used when fungal infections are suspected; anti-anaerobic drugs can be added when combined anaerobic infections are suspected.

Anti-tuberculosis drugs

If it is clear that tuberculous lymphadenitis is present, regular anti-tuberculosis treatment is required, and the commonly used drugs include isoniazid and rifampicin.

Others

Lymphadenitis caused by filariasis infection, syphilis, soft chancre, etc., actively cooperate with the doctor for the treatment of the original disease.

Surgical treatment

If an abscess has formed, in addition to the application of antibacterial drugs, incision and drainage are also required.

Prognosis

Most cases of inguinal lymphadenitis can be cured after active treatment, and early diagnosis and timely treatment is the key.

Cure

Acute lymphadenitis can be basically cured after active anti-inflammatory treatment.

A small number of acute lymphadenitis without timely and effective treatment can be transformed into chronic inflammation, which is difficult to be cured.

The prognosis of special types of lymphadenitis varies according to the primary disease.

Early diagnosis and timely treatment of inguinal lymphadenitis is the key.

Daily routine

Patients with inguinal lymphadenitis need to pay attention to diet and daily life, pay close attention to changes in the condition, and undergo regular review.

Daily management

Dietary management

Daily diet should be nutritionally balanced.

Avoid excessive intake of stimulating foods.

Allergic patients should avoid excessive intake of allergy-inducing foods.

Lifestyle management

Bathe regularly, change underwear frequently and keep skin dry.

Avoid unclean sexual intercourse, pay attention to wearing condoms, and fix sexual partners.

Appropriate physical exercise and outdoor activities.

Avoid field activities in unfamiliar areas and avoid mosquito bites during outdoor activities. Domestic pets should be vaccinated, dewormed regularly and have health checkups.

Follow-up and review

Follow the doctor’s instructions for proper medication and treatment, and have regular checkups.

Prevention

Appropriate physical exercise, strengthen nutrition, enhance immunity, reduce the risk of infection of the organism [10].

Do not go to unfamiliar field activities, avoid mosquito bites during field activities, and pay attention to good protection when contacting with non-domesticated animals.

Pay attention to personal hygiene, avoid unclean sexual intercourse.

Actively treat the primary disease.